I hope physicians are trained to cope with all the problems the patients have, not just the problems the physicians recognize. The Canadian study refers to the high level of recognition by physicians of hypertension in patients in the Virginia study; it comments on the similarities, not on the differences between the two investigations. I doubt whether people in Canada are significantly different from those in the United States. The Virginia.. study involved more physicians than 'the Canadian one and its results are similar in most respects to those of the national ambulatory care study of the US National Center for Health Statistics.1 The national ambulatory care study found the distribution of problems seen to be similar but not identical to that found in surveys of the US population. These surveys examined probability samples of the US public to verify the prevalence of common conditions such as hypertension, diabetes, coronary artery disease, gout and rheumatoid disease.24 Hypertension is the most common chronic disease in the US; its prevalence is between 15% and 18% .5,6 Coronary artery disease is the most common cause of morbidity and death. Diabetes affects 2% or more of the population. Similar studies show the prevalence of conditions in the general population to be greater than that recognized by family practitioners. One would expect persons with chronic disease to constitute a higher percentage of the physician's practice than of the general population. Conditions of "soft addiction", such as obesity, alcoholism and smoking are very common in the general population, although the last two were not recognized as problems in these studies. The article by Warrington and colleagues suggests to me the failure on the part of the physicians sampled to recognize common conditions and emotional problems in their patients. All chronic diseases have associated emotional problems that need special psychosocial skills and attitudes. Or perhaps, as I hope is true, they failed to code them. This is borne out by the article on the treatment of hypertension in a family practice by K.V. Rudnick and associates in a subsequent issue of the Journal (117: 492, 1977). C.M.G. BUTTERY, MD, MPH Associate professor Department of family medicine Eastern Virginia Medical School Norfolk, Va
3. Blood Pressure of Adults by Race and Area; United States 1960-1964, Public Health Service publ no 1000, ser 11, no 5, Washington, US Govt Printing Office, July 1964 4. Hypertension and Hypertensive Heart Disease in Adults; United States 1960-1962, Public Health Service pubi no 1000, ser 11, no 13, Washington, US Govt Printing Office, May 1966 5. Blood Pressure of Persons 6-74 Years of Age in the United States, advance data from vital and health statistics of the National Center for Health Statistics, no 1, Hyattsville, Md, NCHS, Oct 18, 1976 6. Hypertension; United States, 1974, advance data from vital and health statistics of the National Center for Health Statistics, no 2, Hyattsville, Md, NCHS, Nov. 8, 1976
Autopsy of an Egyptian mummy (Nakht-ROM I) To the editor: It was interesting to learn about the contributions of so many disciplines to the elaborate autopsy of the mummy of Nakht (ROM I), and about the use of advanced technologies to extract the greatest amount of information (Can Med Assoc J 117: 461, 1977). Some presumably highpriced equipment was used and no expense was spared to do a thorough job, even if the various experts' services were donated. It therefore seems a great pity that one extremely valuable means of research either was not reported or was omitted, namely carbon-14 dating of the body or the cloth wrappings. As little as 50 g of the body, and even less of the wrappings (maybe 20 g), would have had to be sacrificed. The article by N.B. Millet on the archeologic background (page 462) claims accurate dating of Nakht, but the only thing that seems certain is that this boy-weaver lived in the XXth Dynasty during the reign of the predecessor of Ramesses III. Conventional Egyptian chronology has long placed the start of the XXth Dynasty at about 1200 BC, but this is now being challenged strongly. As a matter of fact, the first person to put a date on Ramesses III's accession was J.C. Prichard, a Scottish psychiatrist, who, in 1819, stated that it was 1147 BC; that was before anybody had succeeded in deciphering a Single hieroglyph. The person who challenges the conventional view is another psychiatrist, Dr. Immanuel Velikovsky, who at one time practised in Tel Aviv. Dr. Velikovsky's reconstruction of Egyptian chronology covers a 1200year span from the time of the Exodus to the conquest by Alexander the Great in 332 BC. This fascinating and scholarly work will eventually be completed in four volumes: the first, published in 1952 and entitled "Ages in Chaos covered the earlier part of this span, and "Peoples of the Sea"2 covers the last 200 years approximately, down to Alexander. Two further volumes will deal with the intervening centuries and one of them, to be entitled "Ramesses II and His Time", is due to appear " 1
References 1. The National Ambulatory Medical Care Survey; 1973 Summary, United States, May 1973April 1974, DHEW pubi no (HRA) 76-1772, Washington, US Govt Printing Office, October 1975 2. Blood Pressure of Adults by Age and Sex; United States 1960-1962, Public Health Service pubi no 1000, ser 11, no 4, Washington, US Govt Printing Office. June 1964
20 CMA JOURNAL/JANUARY 7, 1978/VOL. 118
early this year. Dr. Velikovsky's books represent a sustained effort in real-life detective work; they richly repay careful reading because he is at great pains to explain all his clues and supply all his references. His reconstruction has a strong appeal to anyone who has no axe to grind and no vested interest in maintaining the conventional chronology. Dr. Velikovsky gathers and arranges a wealth of evidence to show why the presently accepted order of the dynasties is arbitrary and wrong, and how the same events have come to be described twice in some instances, so that Egyptian history has been artificially extended anywhere from about 500 years (e.g., at the time of Tutankhamun) to nearly 800 years (at the time of Ramesses III and his predecessor). It is this period, when Nakht is said to have lived, that is painstakingly reconstructed in "Peoples of the Sea". Furthermore, the book contains a threechapter supplement that explains in detail exactly how the conventional chronology came about, and how its astronomic support - always triumphantly quoted as unassailable - is actually rooted in a fallacy. Any nonexpert who takes the trouble to grasp the intricate details set out in that supplement can hardly help but agree with Dr. Velikovsky that the conventional chronology "does not seem so stable and secure as once thought; it looks more like an aggregation of many unconnected things, each unstable by itself, piled precariously one upon the other."2 Up to now there has been a scarcity of 14C dates on objects from the New Kingdom of Egypt. Objects of organic origin are needed, of course, and some are far more suitable than others. All such ancient objects are precious, and the conventional chronology has hitherto been regarded as more accurate than 14C dating. Egyptologists are prone to suggest that in these cases the 14C method is being tested, the date of the object being already "known". It is believed widely that a number of 14C dates of Egyptian sources have been discarded if they have turned out to be a few centuries out of line. One archeologist, Professor Brew,3 has been quoted as saying: "If a 14C date supports our theories, we put it in the main text. If it does not entirely contradict them, we put it in a foot-note. And if it is completely 'out-of-date' we just drop it." Two British Museum tests (BM-642A and BM-642B), the results of which, were never officially published, yielded dates about 500 years too recent for the accepted chronology but they neatly support Dr. Velikovsky's theory; they were conducted on reed and palm nut kernels from Tutankhamun's tomb. Chips of wood from
his casket gave a date that meant that the saplings that eventually grew into the timber from which these chips came could not have begun to grow until 2 to 3 centuries after his death (according to the accepted date). The results of that test (P-726) were published.4 The layman in archeologic matters may well wonder what all the fuss is about. The answer is that the chronology of the entire ancient East is geared to that of Egypt, so that if Dr. Velikovsky is right, as seems very likely, the history of the cultures of Greece and Crete, the dates of some Assyrian and Babylonian kings, and in fact the history of the entire Middle East will have to be rewritten. The mysterious "Dark Age" of Greece would become a chronologic artefact and simply disappear. If there is agreement beyond any possibility of doubt that the mummy of Nakht belongs to the reign of the predecessor of Ramesses III, it would surely be an ideal subject for 14C dating to help establish which chronology is nearer to the truth, especially when the gap between them is 800 years at this point.. I am told a 14C test costs $100. I am cheerfully prepared to wager this amount that Dr. Velikovsky is right; specifically, that the mummy belongs to the 4th rather than to the 12th century BC. Dr. Velikovsky is always anxious to have his theories put to any fair test, but whether supporters of the conventional view would be willing to take the risk is another question. It looks as if a golden opportunity has so far been allowed to slip by. Is it too late to reconsider? J.D.H. ILES, MB, B CH 44 Fairfield Rd. Toronto, Ont.
References 1. VELIKOVSKY I: Ages In Chaos, New York, Doubleday, 1952
2. Idem: Peoples of the Sea (Ages ii. Chaos series, vol 4), New York, Doubleday, 1977 3. SAVE-SODERBERGH T, OLssoN IU: Proceedings of the 12th Annual Nobel Symposium at Uppsala, 1969 4. STUCKENRATH R JR, RALPH EK: University of Pennsylvania radiocarbon dates VIII. Radio-
carbon 7: 187, 1965
Suppurative conjunctivitis caused by Versinia enterocolitica To the editor: Yersinia enterocolitica infections are being suspected and recognized in Canada with increasing frequency.1'1 Their most common modes of presentation are as gastroenteritis, enterocolitis, terminal ileitis and mesenteric adenitis. The organisms are isolated most commonly from enteric contents, but also from mesenteric glands, cutaneous lesions, abscesses, cerebro-
spinal fluid and the bloodstream. The infection may be associated with nonsuppurative complications such as arthritis, erythema nodosum and Reiter's syndrome and rarely with myocarditis and hepatitis. In view of the increasing importance of the organism as a cause of infection, the Ontario Ministry of Health instituted at the end of 1974 a national reference service for Y. enterc'colitica and Y. pseudotuberculosis infections, both of which have been well reviewed by the Canadian reference centre1'2 and authors in Finland3'4 and Sweden.5'6 I report the following case because of its unusual presentation as suppurative conjunctivitis and adenitis in the absence of any other signs or symptoms that are usually associated with Y. enterocolitica infection.
A 44-year-old man, a railway mechanic, was admitted to St. Paul's Hospital, Vancouver, Nov. 22, 1975. Twelve days earlier he had first noticed redness of his left eye, which was associated with a copious yellow discharge. It became progressively worse in spite of the instillation of gentamicin drops and ampicillin orally. One week after the onset of his illness the area in front of the left ear had become swollen and tender. This became worse and severe frontal headache developed that became so severe as to be intolerable. On admission the patient had severe conjunctivitis and chemosis affecting the left eye, which was almost closed and discharging pus. The left side of his face was swollen owing to tender enlargement of the preauricular node. The right eye was normal. Temperature was 37.5 0C. Physical examination disclosed no other abnormality, and there was no evidence of arthritis or erythema nodosum. There was no history of trauma or of previous eye infection and no family member had a similar condition or any recent history of illness. The family kept a dog that was in good health and there had been no contact with any other animals. The leukocyte count was 12.2 X 109/L (71% neutrophils and 2% staff cells). A gram smear of the conjunctival exudate showed pus cells and gram-negative bacilli; culture produced a pure growth of Y. enterocolitica subsequently defined as biotype 1, serotype 0:4.32. The organisms were found by the Kirby-Bauer method to be sensitive to ampicillin, tetracycline, chloramphenicol and kanamycin. Tests for susceptibility to penicillin were omitted. Treatment was instituted with chloramphenicol, 500 mg q6h orally; penicillin G, 12.5 X 106 U q6h intravenously; and chloramphenicol drops instilled into the conjunctival sac. His temperature rose initially but returned to normal after 2 days. The inflammation subsided quickly. When the patient was discharged 7 days later the left eye was still slightly red but cultures from specimens were sterile. There was no relapse within the following 2 months.
22 CMA JOURNAL/JANUARY 7, 1978/VOL. 118
Dyazide® To lower blood pressure and conserve potassium. Before prescribing, see complete prescribing information in CPS. The following is a brief summary. ADULT DOSAGE: Hypertension: Starting dosage is one tablet twice daily after meals. Dosage can be subsequently increased or decreased according to patient's need. If two or more tablets per day are needed, they should be given in divided doses. Edema: Starting dosage is one tablet twice daily after meals. When dry weight is reached, the patient may be maintained on one tablet daily. Maximum dosage four tablets daily. INDICATIONS: Mild to moderate hypertension in patients who have developed hypokalemia and in patients in whom potassium depletion is considered especially dangerous (e.g. digitalized patients). Medical opinion is not unanimous regarding the incidence and/or clinical significance of hypokalemia occurring among hypertensive patients treated with thiazide-like diuretics alone, and concerning the use of potassium-sparing combinations as routine therapy in hypertension. Edema of congestive heart failure, cirrhosis, nephrotic syndrome, steroid-induced edema and idiopathic edema. Dyazide is useful in edematous patients whose response to other diuretics is inadequate. CONTRAINDICATIONS: Progressive renal dysfunction (including increasing oliguria and azotemia) or increasing hepatic dysfunction. Hypersensitivity. Elevated serum potassium. Nursing mothers. WARNINGS: Do not use potassium supplementation or other potassium-conserving agents with Dyazide since hyperkalemia may result. Hyperkalemia (>5.4 mEq/l) has been reported ranging in incidence from 40/a in patients less than 60 years of age to 1 2o/. in patients 60 and older, with an overall incidence of less than 8./o. Rare cases have been associated with cardiac irregularities. Make periodic serum potassium determinations, particularly in the elderly, in diabetics, and in suspected or confirmed renal insufficiency. If hyperkalemia develops, withdraw Dyazide and substitute a thiazide alone. Hypokalemia is less common than with thiazides alone, but if it occurs it may precipitate digitalis intoxication. PRECAUTIONS: Check laboratory data (e.g. BUN, serum electrolytes) and ECG's periodically, especially in the elderly, in diabetics, in renal insufficiency, and in those who have developed hyper kalemia on Dyazide' previously. Electrolyte imbalance may occur, especially where salt-restricted diets or prolonged high-dose therapy is used. Observe acutely ill cirrhotic patients for early signs of impending coma. Reversible nitrogen retention may be seen. Observe patients regularly for blood dyscrasias, liver damage or other idiosyncratic reactions: perform appropriate laboratory studies as required. Sensitivity reactions may occur, particularly in patients with history of allergy or bronchial asthma. Periodic blood studies are recommended in cirrhotics with splenomegaly. Adjust dosage of other antihypertensive agents given concomitantly. Antihypertensive effects of Dyazide may be enhanced in the post-sympathectomy patient. Hyperglycemia and glycosuria may occur. Insulin requirement may be altered in diabetics. Hyperuricemia and gout may occur. Thiazides have been reported to exacerbate or activate systemic lupus erythematosus. Pathological changes in the parathyroid glands have been reported with prolonged thiazide therapy. Triamlerene may cause a decreasing alkali reserve, with the possibility of metabolic acidosis. Serum transaminase elevations sometimes occur with Dyazide. Thiazides can decrease arterial responsiveness to norepinephrine and increase tubocurarine's paralyzing effect; exercise caution in patients undergoing surgery. Thiazides cross the placental barrier and appear in breast milk; this may result in fetal or neonatal hyperbilirubinemia, thrombocytopenia, altered carbohydrate metabolism and possible other adverse reactions that have occurred in the adult. Use in pregnancy only when deemed necessary for the patient's welfare. ADVERSE REACTIONS: The following adverse reactions have been associated with the use of thiazide diuretics or triamterene: Gastrointestinal: dry mouth, anorexia, gastric irritation, nausea, vomiting, diarrhea, constipation, jaundice (intra-hepatic cholestatic) pancreatitis, sialadenitis. Nausea can usually be prevented by giving the drug after meals. It should be noted that symptoms of nausea and vomiting can also be indicative of electrolyte imbalance (See Precautions). Central nervous system: dizziness, vertigo, paresthesias, headache, xanthopsia. Dermatologic - Hypersensitivity: fever, purpura, anaphylaxis, photosensitivity, rash, urticaria, necrotizing angiitis. Hematologic: leukopenia, thrombocytopenia, agranulocytosis, aplastic anemia. Cardiovascular: orthostatic hypotension may occur and may be potentiated by alcohol, barbiturates, or narcotics. Electrolyte imbalance (See Precautions). Miscellaneous: hyperglycemia, glycosuria, hyperuricemia, muscle spasm, weakness, restlessness, transient blurred vision. SUPPLY: Scored light orange compressed tablets monogrammed SKFE93 in bottles of 100, 500, lOQOand 2,500. DIN 161528.
Dyazide 25 mg hydrochiorothiazide 50 mg triamterene
makes sense
[..]
. Smith Kline & French Canada Ltd. S Montreal, Quebec H4M 2L6
3. Blood Pressure of Adults by Race and Area; United States 1960-1964, Public Health Service publ no 1000, ser 11, no 5, Washington, US Govt Printing Office, July 1964 4. Hypertension and Hypertensive Heart Disease in Adults; United States 1960-1962, Public Health Service pubi no 1000, ser 11, no 13, Washington, US Govt Printing Office, May 1966 5. Blood Pressure of Persons 6-74 Years of Age in the United States, advance data from vital and health statistics of the National Center for Health Statistics, no 1, Hyattsville, Md, NCHS, Oct 18, 1976 6. Hypertension; United States, 1974, advance data from vital and health statistics of the National Center for Health Statistics, no 2, Hyattsville, Md, NCHS, Nov. 8, 1976
Autopsy of an Egyptian mummy (Nakht-ROM I) To the editor: It was interesting to learn about the contributions of so many disciplines to the elaborate autopsy of the mummy of Nakht (ROM I), and about the use of advanced technologies to extract the greatest amount of information (Can Med Assoc J 117: 461, 1977). Some presumably highpriced equipment was used and no expense was spared to do a thorough job, even if the various experts' services were donated. It therefore seems a great pity that one extremely valuable means of research either was not reported or was omitted, namely carbon-14 dating of the body or the cloth wrappings. As little as 50 g of the body, and even less of the wrappings (maybe 20 g), would have had to be sacrificed. The article by N.B. Millet on the archeologic background (page 462) claims accurate dating of Nakht, but the only thing that seems certain is that this boy-weaver lived in the XXth Dynasty during the reign of the predecessor of Ramesses III. Conventional Egyptian chronology has long placed the start of the XXth Dynasty at about 1200 BC, but this is now being challenged strongly. As a matter of fact, the first person to put a date on Ramesses III's accession was J.C. Prichard, a Scottish psychiatrist, who, in 1819, stated that it was 1147 BC; that was before anybody had succeeded in deciphering a Single hieroglyph. The person who challenges the conventional view is another psychiatrist, Dr. Immanuel Velikovsky, who at one time practised in Tel Aviv. Dr. Velikovsky's reconstruction of Egyptian chronology covers a 1200year span from the time of the Exodus to the conquest by Alexander the Great in 332 BC. This fascinating and scholarly work will eventually be completed in four volumes: the first, published in 1952 and entitled "Ages in Chaos covered the earlier part of this span, and "Peoples of the Sea"2 covers the last 200 years approximately, down to Alexander. Two further volumes will deal with the intervening centuries and one of them, to be entitled "Ramesses II and His Time", is due to appear " 1
References 1. The National Ambulatory Medical Care Survey; 1973 Summary, United States, May 1973April 1974, DHEW pubi no (HRA) 76-1772, Washington, US Govt Printing Office, October 1975 2. Blood Pressure of Adults by Age and Sex; United States 1960-1962, Public Health Service pubi no 1000, ser 11, no 4, Washington, US Govt Printing Office. June 1964
20 CMA JOURNAL/JANUARY 7, 1978/VOL. 118
early this year. Dr. Velikovsky's books represent a sustained effort in real-life detective work; they richly repay careful reading because he is at great pains to explain all his clues and supply all his references. His reconstruction has a strong appeal to anyone who has no axe to grind and no vested interest in maintaining the conventional chronology. Dr. Velikovsky gathers and arranges a wealth of evidence to show why the presently accepted order of the dynasties is arbitrary and wrong, and how the same events have come to be described twice in some instances, so that Egyptian history has been artificially extended anywhere from about 500 years (e.g., at the time of Tutankhamun) to nearly 800 years (at the time of Ramesses III and his predecessor). It is this period, when Nakht is said to have lived, that is painstakingly reconstructed in "Peoples of the Sea". Furthermore, the book contains a threechapter supplement that explains in detail exactly how the conventional chronology came about, and how its astronomic support - always triumphantly quoted as unassailable - is actually rooted in a fallacy. Any nonexpert who takes the trouble to grasp the intricate details set out in that supplement can hardly help but agree with Dr. Velikovsky that the conventional chronology "does not seem so stable and secure as once thought; it looks more like an aggregation of many unconnected things, each unstable by itself, piled precariously one upon the other."2 Up to now there has been a scarcity of 14C dates on objects from the New Kingdom of Egypt. Objects of organic origin are needed, of course, and some are far more suitable than others. All such ancient objects are precious, and the conventional chronology has hitherto been regarded as more accurate than 14C dating. Egyptologists are prone to suggest that in these cases the 14C method is being tested, the date of the object being already "known". It is believed widely that a number of 14C dates of Egyptian sources have been discarded if they have turned out to be a few centuries out of line. One archeologist, Professor Brew,3 has been quoted as saying: "If a 14C date supports our theories, we put it in the main text. If it does not entirely contradict them, we put it in a foot-note. And if it is completely 'out-of-date' we just drop it." Two British Museum tests (BM-642A and BM-642B), the results of which, were never officially published, yielded dates about 500 years too recent for the accepted chronology but they neatly support Dr. Velikovsky's theory; they were conducted on reed and palm nut kernels from Tutankhamun's tomb. Chips of wood from
his casket gave a date that meant that the saplings that eventually grew into the timber from which these chips came could not have begun to grow until 2 to 3 centuries after his death (according to the accepted date). The results of that test (P-726) were published.4 The layman in archeologic matters may well wonder what all the fuss is about. The answer is that the chronology of the entire ancient East is geared to that of Egypt, so that if Dr. Velikovsky is right, as seems very likely, the history of the cultures of Greece and Crete, the dates of some Assyrian and Babylonian kings, and in fact the history of the entire Middle East will have to be rewritten. The mysterious "Dark Age" of Greece would become a chronologic artefact and simply disappear. If there is agreement beyond any possibility of doubt that the mummy of Nakht belongs to the reign of the predecessor of Ramesses III, it would surely be an ideal subject for 14C dating to help establish which chronology is nearer to the truth, especially when the gap between them is 800 years at this point.. I am told a 14C test costs $100. I am cheerfully prepared to wager this amount that Dr. Velikovsky is right; specifically, that the mummy belongs to the 4th rather than to the 12th century BC. Dr. Velikovsky is always anxious to have his theories put to any fair test, but whether supporters of the conventional view would be willing to take the risk is another question. It looks as if a golden opportunity has so far been allowed to slip by. Is it too late to reconsider? J.D.H. ILES, MB, B CH 44 Fairfield Rd. Toronto, Ont.
References 1. VELIKOVSKY I: Ages In Chaos, New York, Doubleday, 1952
2. Idem: Peoples of the Sea (Ages ii. Chaos series, vol 4), New York, Doubleday, 1977 3. SAVE-SODERBERGH T, OLssoN IU: Proceedings of the 12th Annual Nobel Symposium at Uppsala, 1969 4. STUCKENRATH R JR, RALPH EK: University of Pennsylvania radiocarbon dates VIII. Radio-
carbon 7: 187, 1965
Suppurative conjunctivitis caused by Versinia enterocolitica To the editor: Yersinia enterocolitica infections are being suspected and recognized in Canada with increasing frequency.1'1 Their most common modes of presentation are as gastroenteritis, enterocolitis, terminal ileitis and mesenteric adenitis. The organisms are isolated most commonly from enteric contents, but also from mesenteric glands, cutaneous lesions, abscesses, cerebro-
spinal fluid and the bloodstream. The infection may be associated with nonsuppurative complications such as arthritis, erythema nodosum and Reiter's syndrome and rarely with myocarditis and hepatitis. In view of the increasing importance of the organism as a cause of infection, the Ontario Ministry of Health instituted at the end of 1974 a national reference service for Y. enterc'colitica and Y. pseudotuberculosis infections, both of which have been well reviewed by the Canadian reference centre1'2 and authors in Finland3'4 and Sweden.5'6 I report the following case because of its unusual presentation as suppurative conjunctivitis and adenitis in the absence of any other signs or symptoms that are usually associated with Y. enterocolitica infection.
A 44-year-old man, a railway mechanic, was admitted to St. Paul's Hospital, Vancouver, Nov. 22, 1975. Twelve days earlier he had first noticed redness of his left eye, which was associated with a copious yellow discharge. It became progressively worse in spite of the instillation of gentamicin drops and ampicillin orally. One week after the onset of his illness the area in front of the left ear had become swollen and tender. This became worse and severe frontal headache developed that became so severe as to be intolerable. On admission the patient had severe conjunctivitis and chemosis affecting the left eye, which was almost closed and discharging pus. The left side of his face was swollen owing to tender enlargement of the preauricular node. The right eye was normal. Temperature was 37.5 0C. Physical examination disclosed no other abnormality, and there was no evidence of arthritis or erythema nodosum. There was no history of trauma or of previous eye infection and no family member had a similar condition or any recent history of illness. The family kept a dog that was in good health and there had been no contact with any other animals. The leukocyte count was 12.2 X 109/L (71% neutrophils and 2% staff cells). A gram smear of the conjunctival exudate showed pus cells and gram-negative bacilli; culture produced a pure growth of Y. enterocolitica subsequently defined as biotype 1, serotype 0:4.32. The organisms were found by the Kirby-Bauer method to be sensitive to ampicillin, tetracycline, chloramphenicol and kanamycin. Tests for susceptibility to penicillin were omitted. Treatment was instituted with chloramphenicol, 500 mg q6h orally; penicillin G, 12.5 X 106 U q6h intravenously; and chloramphenicol drops instilled into the conjunctival sac. His temperature rose initially but returned to normal after 2 days. The inflammation subsided quickly. When the patient was discharged 7 days later the left eye was still slightly red but cultures from specimens were sterile. There was no relapse within the following 2 months.
22 CMA JOURNAL/JANUARY 7, 1978/VOL. 118
Dyazide® To lower blood pressure and conserve potassium. Before prescribing, see complete prescribing information in CPS. The following is a brief summary. ADULT DOSAGE: Hypertension: Starting dosage is one tablet twice daily after meals. Dosage can be subsequently increased or decreased according to patient's need. If two or more tablets per day are needed, they should be given in divided doses. Edema: Starting dosage is one tablet twice daily after meals. When dry weight is reached, the patient may be maintained on one tablet daily. Maximum dosage four tablets daily. INDICATIONS: Mild to moderate hypertension in patients who have developed hypokalemia and in patients in whom potassium depletion is considered especially dangerous (e.g. digitalized patients). Medical opinion is not unanimous regarding the incidence and/or clinical significance of hypokalemia occurring among hypertensive patients treated with thiazide-like diuretics alone, and concerning the use of potassium-sparing combinations as routine therapy in hypertension. Edema of congestive heart failure, cirrhosis, nephrotic syndrome, steroid-induced edema and idiopathic edema. Dyazide is useful in edematous patients whose response to other diuretics is inadequate. CONTRAINDICATIONS: Progressive renal dysfunction (including increasing oliguria and azotemia) or increasing hepatic dysfunction. Hypersensitivity. Elevated serum potassium. Nursing mothers. WARNINGS: Do not use potassium supplementation or other potassium-conserving agents with Dyazide since hyperkalemia may result. Hyperkalemia (>5.4 mEq/l) has been reported ranging in incidence from 40/a in patients less than 60 years of age to 1 2o/. in patients 60 and older, with an overall incidence of less than 8./o. Rare cases have been associated with cardiac irregularities. Make periodic serum potassium determinations, particularly in the elderly, in diabetics, and in suspected or confirmed renal insufficiency. If hyperkalemia develops, withdraw Dyazide and substitute a thiazide alone. Hypokalemia is less common than with thiazides alone, but if it occurs it may precipitate digitalis intoxication. PRECAUTIONS: Check laboratory data (e.g. BUN, serum electrolytes) and ECG's periodically, especially in the elderly, in diabetics, in renal insufficiency, and in those who have developed hyper kalemia on Dyazide' previously. Electrolyte imbalance may occur, especially where salt-restricted diets or prolonged high-dose therapy is used. Observe acutely ill cirrhotic patients for early signs of impending coma. Reversible nitrogen retention may be seen. Observe patients regularly for blood dyscrasias, liver damage or other idiosyncratic reactions: perform appropriate laboratory studies as required. Sensitivity reactions may occur, particularly in patients with history of allergy or bronchial asthma. Periodic blood studies are recommended in cirrhotics with splenomegaly. Adjust dosage of other antihypertensive agents given concomitantly. Antihypertensive effects of Dyazide may be enhanced in the post-sympathectomy patient. Hyperglycemia and glycosuria may occur. Insulin requirement may be altered in diabetics. Hyperuricemia and gout may occur. Thiazides have been reported to exacerbate or activate systemic lupus erythematosus. Pathological changes in the parathyroid glands have been reported with prolonged thiazide therapy. Triamlerene may cause a decreasing alkali reserve, with the possibility of metabolic acidosis. Serum transaminase elevations sometimes occur with Dyazide. Thiazides can decrease arterial responsiveness to norepinephrine and increase tubocurarine's paralyzing effect; exercise caution in patients undergoing surgery. Thiazides cross the placental barrier and appear in breast milk; this may result in fetal or neonatal hyperbilirubinemia, thrombocytopenia, altered carbohydrate metabolism and possible other adverse reactions that have occurred in the adult. Use in pregnancy only when deemed necessary for the patient's welfare. ADVERSE REACTIONS: The following adverse reactions have been associated with the use of thiazide diuretics or triamterene: Gastrointestinal: dry mouth, anorexia, gastric irritation, nausea, vomiting, diarrhea, constipation, jaundice (intra-hepatic cholestatic) pancreatitis, sialadenitis. Nausea can usually be prevented by giving the drug after meals. It should be noted that symptoms of nausea and vomiting can also be indicative of electrolyte imbalance (See Precautions). Central nervous system: dizziness, vertigo, paresthesias, headache, xanthopsia. Dermatologic - Hypersensitivity: fever, purpura, anaphylaxis, photosensitivity, rash, urticaria, necrotizing angiitis. Hematologic: leukopenia, thrombocytopenia, agranulocytosis, aplastic anemia. Cardiovascular: orthostatic hypotension may occur and may be potentiated by alcohol, barbiturates, or narcotics. Electrolyte imbalance (See Precautions). Miscellaneous: hyperglycemia, glycosuria, hyperuricemia, muscle spasm, weakness, restlessness, transient blurred vision. SUPPLY: Scored light orange compressed tablets monogrammed SKFE93 in bottles of 100, 500, lOQOand 2,500. DIN 161528.
Dyazide 25 mg hydrochiorothiazide 50 mg triamterene
makes sense
[..]
. Smith Kline & French Canada Ltd. S Montreal, Quebec H4M 2L6
